2008 Certified
Surgical
Technologist (CST)
Examination
Application
INSTRUCTIONS:
Please READ THIS ENTIRE PAGE, and PRINT CLEARLY AND COMPLETELY all information requested. Allow 4-6 weeks for processing of your
examination application. For questions, call NBSTSA at 1-800-707-0057.
The application form must be typed or legibly printed using blue or black ink.
1. Select the option which applies to you, and ATTACH THE DOCUMENTS indicated as required for review of that option.
2. Attach proof of identification, and photo as required.
3. Include payment information.
____________________________________________________________________________________________________________
Last Name, First, Middle Initial (PLEASE PRINT)
____________________________________________________________________________________________________________
Maiden Name Other Name(s) You Have Used (if applicable, include documentation of name change)
____________________________________________________________________________________________________________
Mailing Address (include apartment # if applicable) City State Zip Code
(____)________________ (_______)_______________ (______)___________________
Home Phone Work Phone Alternate Number
__________________________ _______________________________________
Social Security Number Email
Are you a National Member of AST? O No O Yes, Membership Number___________________________________________________
NOTE: NBSTSA requires original signatures on all application forms; therefore, faxed copies of the completed applications will not be accepted in the NBSTSA office. If you have any questions about completing this application, please contact the NBSTSA Certification Department directly at (800) 707-0057 or you may e-mail questions to mail@NBSTSA.org.
NEW APPLICANT:
____________________________________________________________________________________________________________
Name of School City, State
Documentation required for review: Transcripts, diplomas or a notarized signed letter from the program director of completion of program.
NOTE: The program director’s letter showing completion must be on official school letterhead.
Required Identifying Documents:
q 2 inch by 2 inch Color Passport Quality Photo (white background only)
q Copy of AST Membership Card (if applicable)
q Copy of Driver’s License or State IDTAPE PHOTO HERE
EDUCATION:
Indicate your highest education level achieved by checking the appropriate box provided (check only one box).
O No high school diploma or GED O AA, AS, AAS, or other 2 year degree
O GED O BA, BS, or other 4 year degree
O High school diploma or GED O MA, MS, or MSA level degree
O Certificate O PhD, DVM, DDS, MD, or other professional degree
SPECIAL ACCOMMODATIONS:
Are you requiring special testing arrangements due to physical impairment(s) or documented disability? O Yes O No
If Yes: You must include with this application the one page special examinations accommodations request form.See NBSTSA website for details on special accommodations testing.
FEES:
AST Member - $190. All others $290.
If an application is found to be ineligible, the eligibility processing fee of $45 will not be refunded.
Total enclosed: O $190 O $290
O RUSH: Please rush my application. I’ve enclosed the non-refundable $50 fee in addition to other fees.
*Rush processing available to those who pay with credit card only.
Forms of Payment:
Please provide payment information below: OMoney Order OPersonal Check
O Institutional Check O Visa O MasterCard
(make checks payable to NBSTSA)
____________________________________________________________________________________________________________
Card Number Name (as it appears on card) Expiration Date
________________________________________ _________________________
Signature ___________________________________ Amount Charged $_____________
*Name on Credit Card must match the name on the application
Statement of Integrity: Candidates must sign the following statement.
I do hereby acknowledge that all the information submitted in connection with my application to the certification program is true and
correct to the best of my knowledge. I understand that falsified information on this application is grounds for denial of acceptance for
examination or certification revocation, and may bar me from future certifications.
____________________________________________________________________________________________________
Printed Name of Applicant Signature of Applicant Date
Refund: The following fees are NON-refundable: application processing fees, RUSH processing fee, and/or exam feeafter the approval of the application and issuance of an Authorization to Test letter.
Return this form, the necessary documentation, and entire fee to: National Board of Surgical Technology and Surgical Assisting.6 West Dry Creek Circle, Suite 100, Littleton, CO 80120.
